The Work/Rest Cycle in Anxiety Treatment
Mountain Valley interviewed its executive program director, Zack Schafer, MS, OTR/L, about how our clinical and residential team balance orthodox ERP with complementary modalities to accelerate and sustain treatment results. Zack’s expertise as a mental health occupational therapist helps him wed the efforts or our clinicians and our residential team in ways that make treatment more approachable, practical, and sustainable.
Mountain Valley: Zack, can you briefly describe what ERP is and what makes for an effective exposure?
Zack: ERP, or exposure and response prevention therapy, is a therapeutic intervention that aims to help someone more adaptively respond to their fear (or other emotion) so they can live with greater freedom and agency. In ERP, the premise is not that fear, anxiety, or other emotions are the “problem” per se, but rather that the challenges arise in our response to those emotions.
For example, let’s take someone who experiences social anxiety and responds to this anxiety by staying in bed and avoiding school, or only agreeing to go out in public if they can listen to music on their headphones. For this person, these attempts to reduce or avoid their anxiety—known as “safety behaviors”—are preventing them from fully engaging in their lives. Over reliance on safety behaviors will also lead to worsening anxiety over time—a kind of vicious cycle. The problem is not that they feel anxious, but rather that they react to that fear ineffectively, leading to increased anxiety and problematic avoidance.
ERP works by exposing someone to the things or situations that trigger their fear (Exposure) and coaching them avoid engaging in their maladaptive “safety” responses (Response Prevention).
To provide an example of ERP intervention, let’s go back to the example of above. For this person, an ERP session may look like having them go into a store without any headphones on or going into a store with the headphones and no music. The degree of challenge of the exposure depends on many factors, but the goal is always the same: we want this person to feel their anxiety fully while refraining from using their headphones or engaging in any other strategies that distract, avoid, or otherwise reduce the feeling of their experience.
There are many different schools of thought and theories about what the “goal” of ERP is regarding habituation, inhibitory learning, etc. At Mountain Valley, we use ERP to help residents experience their emotions and regain a sense agency in how they respond, so they can be free to meaningfully participate in their daily lives.
Mountain Valley: What other modalities, activities, and experiences do we employ here that you would consider either supportive of or complementary to ERP?
Zack: As a program we try to address anxiety from a holistic perspective, so we compliment ERP with psychoeducation, skill building, and an experiential milieu focused on decreasing anxiety, managing stress, and promoting adolescent health and well-being. This includes teaching in the moment anxiety management strategies such as breathing techniques, sensory strategies, and tactics to decrease distress. We educate around lifestyle factors and support healthy participation in self-care, diet, exercise, and sleep. We engage kids in restorative exercises, such as walking in nature, yoga, breath work practices, and journaling. We also seek to engage residents in activities that allow for them to center, contemplate, connect, create, and contribute – experiential principles recognized by occupational therapy as essential for hope, resiliency, and well-being.
Mountain Valley: So I know that strict ERP advocates leaning into a normally anxiety producing situation, fully engaging the feelings of distress it elicits, and doing so without engaging in any safety behaviors, i.e. any coping, self-soothing, or accommodation tactic designed to reduce distress. The idea is largely to develop distress tolerance and, in so doing, to indirectly reduce that distress over time, but as a byproduct of ERP, not as the main goal. When and why do we encourage what might be considered safety behaviors at Mountain Valley such as meditation, therapeutic breathing, ice baths, PRN anxiety medications, etc.? We are both athletes and you once described this relationship between ERP and other strategies using an athletic “work, recover, compete” analogy. Can you describe that again here?
Zack: Yes – that is an excellent point. In the traditional delivery of ERP, the goal is to have the person experience their anxiety fully and not engage in strategies to decrease their distress. However, although we are an ERP program, we also promote coping skills, stress reduction, and positive daily experiences. So, it can sound a little confusing and contradictory. But this is where that “athlete” metaphor comes into play.
In this analogy it’s helpful to think of ERP like “training.” The purpose of training in sports is to condition the body and mind to the demands of the task, build the skills needed to complete the task, and to “stress test” one’s limits. The goal of training in sports is to prepare the athlete for the game or event, just like the goal of ERP is prepare a resident for the “game” of life, where exposures and anxiety can happen anywhere. But in both activities, you have to alternative training with rest for the training to be maximally effective. Any elite athlete will tell you that the quality of your rest is just as important as the quality of your training.
That’s why we want make sure there is a balance between doing hard work and engaging in restorative practices. Making everything a challenge and trying to always increase distress as an “exposure” is not sustainable or realistic. However, always engaging in restorative or pleasurable activities, or always waiting for anxiety to go away before we engage in our life, is also not realistic.
Like many things, it’s about balance. Ultimately, we want to help our residents become more dynamic and adaptable so they can be free from the grip of their anxiety. We want them to feel empowered to embrace their anxiety when it is intense and we want to feel empowered to reduce their anxiety in adaptive ways should they need to – but at the end of the day, the goal is always to promote their ability participate and meaningfully engage in their lives.